Intraparenchymal Doppler ultrasound after proximal embolization of the splenic artery in trauma patients

Surgical Management of Solid Organ Injuries

Surgery used to be the treatment of choice in patients with solid organ injuries. This has changed over the past 2 decades secondary to advances in noninvasive diagnostic techniques, increased availability of less invasive procedures, and a better understanding of the natural history of solid organ injuries. Now, nonoperative management (NOM) has become the initial management strategy used for most solid organ injuries. Even though NOM has become the standard of care in patients with solid organ injuries in most trauma centers, surgeons should not hesitate to operate on a patient to control life-threatening hemorrhage.

Preserved function after angioembolisation of splenic injury in children and adolescents: a case control study

BACKGROUND

Non-operative management for blunt splenic injuries was introduced to reduce the risk of overwhelming post splenectomy infection in children. To increase splenic preservation rates, splenic artery embolization (SAE) was added to our institutional treatment protocol in 2002. In the presence of clinical signs of ongoing bleeding, SAE was considered also in children. To our knowledge, the long term splenic function after SAE performed in the paediatric population has not been evaluated and constitutes the aim of the present study.

METHODS

A total of 11 SAE patients less than 17 years of age at the time of injury were included with 11 healthy volunteers serving as matched controls. Clinical examination, medical history, general blood counts, immunoglobulin quantifications and flowcytometric analysis of lymphocyte phenotypes were performed. Peripheral blood smears were examined for Howell-Jolly bodies (H-J bodies) and abdominal ultrasound was performed in order to assess the size and perfusion of the spleen.

RESULTS

On average 4.6 years after SAE (range 1-8 years), no significant differences could be detected between the SAE patients and their controls. Total and Pneumococcus serospecific immunoglobulins and H-J bodies did not differ between the study groups, nor did general blood counts and lymphocyte numbers, including memory B cell proportions. The ultrasound examinations revealed normal sized and well perfused spleens in the SAE patients when compared to their controls.

CONCLUSION

This case control study indicates preserved splenic function after SAE for splenic injury in children. Mandatory immunization to prevent severe infections does not seem warranted.

Time to intervention in patients with splenic injury in a Dutch level 1 trauma centre

BACKGROUND

Timely intervention in patients with splenic injury is essential, since delay to treatment is associated with an increased risk of mortality. Transcatheter Arterial Embolisation (TAE) is increasingly used as an adjunct to non-operative management. The aim of this study was to report time intervals between admission to the trauma room and start of intervention (TAE or splenic surgery) in patients with splenic injury.

METHODS

Consecutive patients with splenic injury aged ≥ 16 years admitted between January 2006 and January 2012 were included. Data were reported according to haemodynamic status (stable versus unstable). In haemodynamically (HD) unstable patients, transfusion requirement, intervention-related complications and the need for a re-intervention were compared between the TAE and splenic surgery group.

RESULTS

The cohort consisted of 96 adults of whom 16 were HD unstable on admission. In HD stable patients, median time to intervention was 105 (IQR 77-188) min: 117 (IQR 78-233) min for TAE compared to 95 (IQR 69-188) for splenic surgery (p=0.58). In HD unstable patients, median time to intervention was 58 (IQR 41-99) min: 46 (IQR 27-107) min for TAE compared to 64 (IQR 45-80) min for splenic surgery (p=0.76). The median number of transfused packed red blood cells was 8 (3-22) in HD unstable patients treated with TAE versus 24 (9-55) in the surgery group (p=0.09). No intervention-related complications occurred in the TAE group and one in the splenic surgery group (p=0.88). Two spleen related re-interventions were performed in the TAE group versus 3 in the splenic surgery group (p=0.73).

CONCLUSIONS

Time to intervention did not differ significantly between HD unstable patients treated with TAE and patients treated with splenic surgery. Although no difference was observed with regard to intervention-related complications and the need for a re-intervention, a trend towards lower transfusion requirement was observed in patients treated with TAE compared to patients treated with splenic surgery. We conclude that if 24/7 interventional radiology facilities are available, TAE is not associated with time loss compared to splenic surgery, even in HD unstable patients.

Non-operative management and immune function after splenic injury

BACKGROUND

There is still considerable controversy about the importance and method of preserving splenic function after trauma. Recognition of the immune function of the spleen and the risk of overwhelming postsplenectomy infection led to the development of spleen-preserving surgery and non-operative management. More recently angiographic embolization has been used to try to reduce failure of conservative management and preserve splenic function.

METHODS

A literature review was performed of the changing treatment of splenic injury over the last century, focusing on whether and how to maintain splenic immune function.

RESULTS

Non-operative management continues to be reported as a successful approach in haemodynamically stable patients without other indications for laparotomy, achieving high success rates in both children and adults. Except for haemodynamic instability, reported predictors of failure of conservative treatment should not be seen as absolute contraindications to this approach. Angiographic embolization is generally reported to increase success rates of non-operative management, currently approaching 95 per cent. However, the optimal use of angioembolization is still debated. Splenic immunocompetence after angioembolization remains questionable, although existing studies seem to indicate preserved splenic function.

CONCLUSION

Non-operative management has become the treatment of choice to preserve splenic immune function. Current knowledge suggests that immunization is unnecessary after angiographic embolization for splenic injury. Identifying a diagnostic test of splenic function will be important for future studies. Most importantly, in efforts to preserve splenic function, care must be taken not to jeopardize patients at risk of bleeding who require early surgery and splenectomy.

Preserved splenic function after angioembolisation of high grade injury

BACKGROUND

After introducing splenic artery embolisation (SAE) in the institutional treatment protocol for splenic injury, we wanted to evaluate the effects of SAE on splenic function and assess the need for immunisation in SAE treated patients.

METHODS

15 SAE patients and 14 splenectomised (SPL) patients were included and 29 healthy blood donors volunteered as controls. Clinical examination, medical history, general blood counts, immunoglobulin quantifications and flowcytometric analysis of lymphocyte phenotypes were performed. Peripheral blood smears from all patients and controls were examined for Howell-Jolly (H-J) bodies. Abdominal doppler, gray scale and contrast enhanced ultrasound (CEUS) were performed on all the SAE patients.

RESULTS

Leukocyte and platelet counts were elevated in both SAE and SPL individuals compared to controls. The proportion of memory B-lymphocytes did not differ significantly from controls in either group. In the SAE group total IgA, IgM and IgG levels as well as pneumococcal serotype specific IgG and IgM antibody levels did not differ from the control group. In the SPL group total IgA and IgG Pneumovax(®) (PPV23) antibody levels were significantly increased, and 5 of 12 pneumococcal serotype specific IgGs and IgMs were significantly elevated. H-J bodies were only detected in the SPL group. CEUS confirmed normal sized and well perfused spleens in all SAE patients.

CONCLUSION

In our study non-operative management (NOM) of high grade splenic injuries including SAE, was followed by an increase in total leukocyte and platelet counts. Normal levels of immunoglobulins and memory B cells, absence of H-J bodies and preserved splenic size and intraparenchymal blood flow suggest that SAE has only minor impact on splenic function and that immunisation probably is unnecessary.

Outcomes of proximal versus distal splenic artery embolization after trauma: a systematic review and meta-analysis

The objective of this systematic review and meta-analysis was to assess the outcomes after angioembolization in blunt trauma patients with splenic injuries and to examine specifically the impact of the technique used. Studies evaluating adult trauma patients who sustained blunt splenic injuries managed by angioembolization were systematically evaluated. The following data were required for inclusion: grade of splenic injury, indication for embolization, and site of embolization (proximal [main splenic artery] or distal [selective]). In addition, major (requiring splenectomy) or minor (not requiring splenectomy) rebleeding, infarction, and infection in relation to the site of embolization (proximal vs. distal) was required. Pooled outcomes were compared between proximal and distal embolizations. To eliminate between-study heterogeneity, a sensitivity analysis was conducted on three reduced sets of studies. Fifteen of 147 evaluated studies were included for analysis. All were retrospective cohort studies and incorporated a total of 479 embolized patients. The overall failure rate of angioembolization was 10.2% (range, 0.0-33.3%). Injury severity and basic demographics did not differ among the study populations. However, the indications for angioembolization (contrast extravasation, large amount of hemoperitoneum, or high-grade splenic injury) differed between the populations but were not associated with a change in the failure rates. Rebleeding was the most common reason for failure; however, it did not differ statistically between the used techniques, and with the 95% confidence interval crossing the 5% zone of clinical indifference, this result was inconclusive. Minor complications occurred statistically and clinically more often after distal than after proximal embolization. The available literature is inconclusive regarding whether proximal or distal embolization should be used to avoid significant rebleeding and larger prospective cohort studies are required. However, both techniques have an equivalent rate of infarctions and infections requiring splenectomy. Minor complications occur more often after distal embolization. This is primarily explained by the higher rate of segmental infarctions after distal embolization.

Laparoscopic treatment of splenic artery aneurysms

OBJECTIVES

The purpose of this study was to report a series of 16 consecutive patients who underwent laparoscopic treatment of splenic artery aneurysms.

METHODS

Over a period of 8 years, patients were selected for the laparoscopic option by a team of specialists that included the vascular surgeon, the interventional radiologist, and the laparoscopic surgeon. The mean size of the aneurysm was 32 mm and most was located at the splenic hilum. They were twice as common in females as in males. Ultrasonography with color Doppler function was used to define intraoperative strategy.

RESULTS

The laparoscopic treatment entailed excision of the aneurysm or its exclusion, usually reserved for distally located lesions. In one patient, laparoscopic resection and robotic anastomosis of the splenic artery was performed to re-establish flow to the spleen. In two patients, the intraoperative decision was added to combine a laparoscopic splenectomy due to insufficient residual arterial flow to the spleen. There was no conversion, or need for re-operation or related mortality. Analysis of intraoperative arterial flow data avoided unnecessary splenectomy following noncritical reduction of flow to the spleen.

CONCLUSIONS

The use of intraoperative color Doppler ultrasonography is essential in deciding the appropriate procedure and whether the spleen should be removed or saved. Early control of the splenic artery proximal to the aneurysm can limit the risk of conversion due to intraoperative bleeding. Distally located aneurysms are more difficult to manage and entail a higher risk of associated splenectomy. The laparoscopic option offers some advantages over the endovascular treatment in selected patients. A multidisciplinary approach is the key to a successful treatment of this uncommon disease.

Transcatheter embolization for delayed hemorrhage caused by blunt splenic trauma

Although the exact benefit of adjunctive splenic artery embolization (SAE) in the nonoperative management (NOM) of patients with blunt splenic trauma has been debated, the role of transcatheter embolization in delayed splenic hemorrhage is rarely addressed. The purpose of this study was to evaluate the effectiveness of SAE in the management of patients who presented at least 3 days after initial splenic trauma with delayed hemorrhage. During a 24-month period 4 patients (all male; ages 19-49 years) presented with acute onset of pain 5-70 days after blunt trauma to the left upper quadrant. Two had known splenic injuries that had been managed nonoperatively. All had computed axial tomography evidence of active splenic hemorrhage or false aneurysm on representation. All underwent successful SAE. Follow-up ranged from 28 to 370 days. These cases and a review of the literature indicate that SAE is safe and effective for NOM failure caused by delayed manifestations of splenic arterial injury.